Beauty Curves Spa Intake Form
Client Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Surgery Information
Surgery Date:
*
-
Month
-
Day
Year
Date
Surgeons Name:
*
Surgeons Phone Number:
*
Surgery type?
*
Lipo 360
Back Lipo
Arm Lipo
Thigh Lipo
Chin Lipo
Tummy Tuck
BBL
Mommy Makeover
Other
How did you hear about us?
*
Instagram
Facebook
Google
Tiktok
Other
Health Data
Do you have any allergies?
*
Yes
No
Other
Current medical conditions.
*
Asthma
Diabetes
Heart problems
Kidney problems
Other
Are you currently taking any medications?
*
Yes
No
Other
Have you been recently hospitalized?
*
Yes
No
Other
Do you have any of the following conditions?
*
Seroma
Fibrosis
None
Location of painful areas.
*
Back
Arms
Legs
Abdominal
None
Other
Consent and Waiver
I, undersigned, agree with the following statements:
*
I authorize Beauty Curves Spa to perform the treatment or necessary massage for my post operative care treatments.
I authorize the use of lotion, oil, and ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the massage treatment.
I understand that this is an alternative treatment, and if there are any medical concerns, I need to talk to my surgeon.
I understand that to schedule my appointment, I need to send a deposit of $25 for an in-office visit or a deposit of $50 for a mobile visit. The deposit will be sent either through Cash App (@beautycurvesspa) Zelle or Apple Pay to 346-354-8109.
I understand that if I am more than 15 minutes late or fail to provide a cancellation notice at least 12 hours in advance, i will lose my deposit.
I understand that Beauty Curves Spa cannot accept any refund request; all services (including packages) purchased, booked, or completed services are final and non-refundable. And I may be able to exchange for another service of equal or lesser value if requested to exchange before 24 Hours of the booked appointment. Services cannot be refunded on because of concern or expected results.
I acknowledge that all information I provided in this form is true and accurate.
Please upload a copy of your Driver's License.
*
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Signature of the Client
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Date Signed
*
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